Nursing Care Plan for Nausea and Vomiting

Nursing Care Plan for Nausea and Vomiting

Vomiting   October 30, 2013

Nausea

Nausea is the sensation (feeling) issued a strong food or want to vomit. Usually accompanied by autonomic signs such as hypersalivation, diaphoresis, tachycardia, pallor, and tachypnea, nausea closely related to anorexia. Nausea caused by distention or irritation in any part of the gastrointestinal tract, but can also be stimulated by higher brain centers.

Nausea is a common symptom of digestive disorders, but may also occur in fluid and electrolyte imbalance, infection, metabolic disorders, endocrine, and cardiac maze. Can also be as a result of drug therapy, surgery, and radiation.

Nausea is also common in the first trimester of pregnancy, nausea can arise from intense pain, anxiety, alcohol poisoning, excessive food or digest food or drinks that do not taste good.


Definition of "Vomit" is a discharge of most or all of the stomach contents food into the stomach occurs after a while, accompanied by contraction of the stomach and abdomen. (Vivian Nanny Lia Dewi, 2010)

In a simple sense of Vomiting is spending the stomach contents through the mouth. Another understanding of the vomiting is a discharge of most or all of the stomach contents food into the stomach occurs after a while, with stomach and abdominal contractions. In the first few hours after birth, the baby may experience vomiting mucus, sometimes with a little blood. Vomiting is not uncommon to settle after breast feeding or food, the situation is probably due to irritation of the gastric mucosa by a number of objects that are ingested during childbirth.

Many causes that can lead to vomiting, namely:

• Virus infection
• Stress
• Gestation
• Drug
• Myocardial infarction
• Uremia
• Other conditions

Therapeutic Intervention

Nausea and vomiting are very few require intervention. However, if left unchecked will lead to dehydration and electrolyte imbalance. Loss of hydrochloric acid from the stomach can cause metabolic alkalosis. Vomiting black, like coffee, showed vomit mixed with blood. Protection of the airway during vomiting are the most important measures to prevent aspiration. Increased risk of aspiration in patients with loss of consciousness, the elderly, and the failure of reflexes. Place the patient in a comfortable position so that vomit out. Beating back while vomiting can lead to aspiration.


Nursing Process in Patients with Nausea and Vomiting

Assessment / data collection

1. Episodes of nausea and vomiting
2. Medical condition
3. Drugs consumed
4. Treatment is being done

Early signs of fluid loss:

1. Weakness
2. Headache
3. Not be able to concentrate
4. Postural hypotension

Further signs of fluid loss:

1. Confused
2. Oliguria
3. Skin cool and moist
4. Chest and abdominal pain

Nursing Diagnosis, Planning, and Implementation

1 . Nausea related to various causes

The desired result :

• Patients expressed no nausea and vomiting .
• Odor-free environment , clean so it does not cause nausea .

Interventions :

1. Give anti- emetic .
2. Oral care , to reduce emesis and increased comfort .
3. Explained to the patient to avoid foods that cause or may cause vomiting .

2 . Risk for aspiration related to decreased reflexes or awareness

The desired result :

• Airway and lung sounds clean patient

Iintervention :

1. Assess whether the patient is in the risk for aspiration .
2. Place the patient in a position to prevent aspiration .

3 . Deficient Fluid Volume

The desired result :

• Patient's vital signs within normal limits .

Interventions :

1. Monitor for signs of hypovolemia to prevent any complications that may occur .
2. Measure body weight each day .
3. Monitor intake output , and vital signs , and vital signs , blood pressure ortohstatik .
4. Give fluids by IV .
5. Discharge monitoring during treatment to prevent deficit and excess fluid .

Evaluation

Patients showed no nausea, lung sounds clean and normal vital signs .

Imbalanced Nutrition : less than body requirements related to nausea and vomiting

Risk for Fluid Volume Deficit related to Vomiting

Definition and Causes of Congenital Talipes Equinovarus

Definition and Causes of Congenital Talipes Equinovarus

Congenital Talipes Equinovarus   October 30, 2013

Definition of CTEV (Congenital talipes Equinovarus)

Congenital talipes Equinovarus (CTEV) or so-called Clubfoot is a common term used to describe a common deformity in which the legs changed from its normal position which is common in children. CTEV is covering flexion deformity of the ankle, inversion of the legs, adduction of the forefoot, and media rotation of the tibia (Priciples of Surgery, Schwartz). Talipes derived from the talus (ankle) and pes (foot), suggesting an abnormality in the leg (foot) which causes the sufferer to walk on his ankle. Equinovarus being derived from the word equino and varus (bent towards the inside / medial).

Congenital talipes Equinovarus is a foot deformity in line twisted heel leg and foot plantar flexion experience. This situation is accompanied with a higher edge in the foot (supination) and the shift of the anterior part of the foot so that it rests on the medial axis of the vertical leg (adduction). With this type of foot arch higher (cavus) and foot in an equinus (plantar flexion). Equino congenital talipes varus is a condition in which the foot in plantar flexion position talocranialis, because musculus tibialis anterior is weak, Inversion ankle because musculus peroneus longus, brevis and Tertius weak, subtalar and midtarsal Adduction.


Causes of Congenital talipes Equinovarus

1. Causes of Congenital talipes Equinovarus until now not known for sure but allegedly are associated with : Persistence of fetal positioning, Genetic, amniotic fluid in the amniotic too little during pregnancy (oligohydramnios), Neuromuscular disorder (sometimes found along with other abnormalities such as Spina bifida or dysplasia of the pelvis). There are several theories that may be linked to CTEV :
2. Chromosomal theory , among others : germinativum defect of cells that are not fertilized and appear before fertilization .
3. Embryonic theory , among others : primary defect that occurs in cells that fertilized germinativum (quoted from Irani and Sherman) which implies a defect occurs between conception and 12 weeks of pregnancy.
4. Autogenic theory, the theory of development is hampered, among other temporary barriers of development that occurs on or around the week of the 7th to the 8th gestation. At this time there is a clear clubfoot deformity, but when these obstacles occur after 9 weeks, there was a clubfoot deformity is mild to moderate. The development of the theory of constraints associated with changes in genetic factors, known as the "Cronon". "Cronon" This is the right time to guide the progressive modification of any structure of the body during development. Therefore, clubfoot occurs due to disruptive elements (local and general) that cause changes in genetic factors (cronon).
5. Fetus theory, namely the development of a mechanical block due to intrauterine crowding.
6. Neurogenic theory, the primary defect in neurogenic tissue.
7. Amiogenic theory, that the primary defect occurs in the muscle.
8. Edward syndrome, which is a genetic disorder of chromosome number 18.
9. Outside influences such as the emphasis on when the baby is still in the womb because at least the amniotic fluid (oligohydramnios)
10. Can be found along with other congenital abnormalities such as spina bifida.
11. Ecstasy use by the mother during pregnancy.

Impaired Verbal Communication related to Acute Tonsillitis

Impaired Verbal Communication related to Acute Tonsillitis

Impaired Verbal Communication   October 29, 2013

Acute Tonsillitis

Tonsillitis is defined simply as the swelling of the tonsils, which are located in the throat, towards the back of the mouth.

Acute tonsillitis comes on quickly and can be caused by a variety of organisms, including viruses, group A beta-hemolytic streptococci (Strep throat)and other types of bacteria.

Acute tonsillitis is caused by both bacteria and viruses and will be accompanied by symptoms of ear pain when swallowing, bad breath, and drooling along with sore throat and fever. In this case, the surface of the tonsil may be bright red or have a grayish-white coating, while the lymph nodes in the neck may be swollen.


Signs of Acute Tonsillitis :

1. There is hyperaemia of pillars, soft palate and uvula.
2. Often the breath is foetid and tongue is coasted.
3. Tonsils are red and swollen with yellowish spots of purulent material presenting at the opening of crypts (acute follicular tonsillitis) or there may be a whitish membrane on the medial surface of tonsil which can be easily wiped away with a swab (acute membranous tonsillitis). The tonsils may be enlarged and congested so much so that they almost meet in
4. the midline along with some oedema of the uvula and soft palate (acute parenchymatous tonsillitis).
5. The jugulodigastric lymph nodes are enlarged and tender.

Symptoms of Acute Tonsillitis:

1. Sore throat.
2. Fever. It may vary from 38 to 40°C and may be associated with chills and rigors. Sometimes, a child presents with an unexplained fever and it is only on examination that an acute tonsillitis is discovered.
3. Difficulty in swallowing. The child may refuse to eat anything due to local pain.
4. Earache. It is either referred pain from the tonsil or the result of acute otitis media which may occur as a complication.
5. Constitutional symptoms. They are usually more marked than seen in simple pharyngitis and may include headache, general body aches, malaise and constipation. There may be abdominal pain due to mesenteric lymphadenitis simulating a clinical picture of acute appendicitis.

Nursing Care Plan for Acute Tonsillitis

Nursing Diagnosis: Impaired verbal communication related to the effects of damage to the area to talk to the brain hemispheres.

Goal:

• Patients are able to communicate to meet their basic needs and show improvement in their communication skills.

Interventions :

1. Do a personal communication with the patient (often but short and easy to understand).
2. Create an atmosphere of acceptance of the changes experienced by the patient.
3. Teach the patient to improve communication techniques.
4. Use non-verbal communication techniques.
5. Collaboration in the implementation of speech therapy.
6. Observation of the patient's ability to communicate in both verbal and non-verbal.

Nursing Care Plan for Tonsillitis

Nursing Care Plan Tonsillectomy

Nursing Interventions for Acute Tonsillitis

6 Trigger Factors of Migraine Attacks

6 Trigger Factors of Migraine Attacks

Migraine   October 29, 2013

Cause of migraine is not known clearly, but this can lead to a primary vascular disorder that usually occurs in women, and many have a strong tendency in the family. Migraines are also caused by the occurrence of a combination of vasodilation (widening of blood vessels) and the release of a chemical substance from nerve fibers that surrounds the blood vessels. When a migraine attack, the temporal artery (the artery that runs around the temple) will be widened. The widening will cause stretching of the nerve fibers around arteries thus stimulating these nerve fibers to release chemicals. This substance will cause inflammation, pain and migraine incredible.

Various factors that can trigger a migraine attack is determined by the presence of hereditary biological defects in the central nervous system. Among others:

1. Hormonal
Hormonal fluctuations are the trigger factor. the presence of glucose increased only 14% of women had an attack during menstruation. Reduced migraine attacks during pregnancy because estrogen levels are relatively high and constant, contrary porspartum first week, 14% of patients experienced severe attack due to lower levels of extradition. Use of the contraceptive pill also causes the frequency of migraine attacks.

2. Menopause
Migraine generally will increase the frequency and severity at the time of menopause. However, some cases improved after menopause. Hormonal therapy with low-dose estrogen can be given to treat migraine attacks after menopause.

3. Food
Variety of foods / substances can trigger a migraine attack. Common migraine triggers are alcohol based vasodilatory effect, where wine and beer are strong triggers. Foods containing tyramine, an amino acid derived from thyroxine.

4. Monosodium Glutamate
Is the most common migraine triggers, namely: headache accompanied by anxiety, dizziness, parastesia and hands, as well as abdominal pain and chest pain.

5. Environment
Environmental changes in the body which include hormonal fluctuations in the menstrual cycle and hormonal changes can lead to getting out of bed acute migraine attacks. Changes in the external environment include the weather, season, air pressure, altitude, and late meals.

6. Sensory stimuli
Flashing light, glare, bright sunlight, or the smell of perfumes, cleaning chemicals, cigarettes, sura noise and extreme temperatures.

Benefits of Early Mobilization for Postoperative Appendectomy

Benefits of Early Mobilization for Postoperative Appendectomy

Health Articles   October 27, 2013

Appendicitis is an inflammation of the appendix are relatively common which can arise without apparent cause or arise after obstruction of the appendix by feces or due to twisting of the appendix or blood vessels. Appendix inflammation causes swelling and pain that can lead to gangrene due to impaired blood supply (Corwin, 2001).

Appendicitis is the most common cause of acute inflammation in the lower right quadrant of the abdominal cavity, as well as the most common causes of emergency abdominal surgery. Approximately 7% of the population will have appendicitis at the same time in their lives, men are more frequently affected than women, and adolescents are more frequent in adults. Although it can occur at any age, appendicitis occurs most often between the ages of 10 and 30 years (Smeltzer and Bare, 2002).

According to Smeltzer and Bare (2002), appendicitis treatment is indicated when the diagnosis of appendicitis has been upheld. Antibiotics and intravenous fluids are given until surgery is performed. Analgesics can be given after the diagnosis is established. Appendectomy (surgery to remove the appendix) as soon as possible to reduce the risk of perforation. Appendectomy can be performed with general or spinal anesthesia with a lower abdominal incision or with a laparoscope, which is the latest method is very effective.

Surgery is a treatment that uses all measures invasive way to unlock or show body parts to be handled. The opening part of the body is generally done by making an incision, after which the part to be handled displayed, performed remedial action that ended with the closure and suturing wounds. The next treatment will be included in the post- surgical care. Surgery or surgery can cause a variety of complaints and symptoms. Complaints and symptoms that often is painful (Sjamsuhidajat, 2002).

Surgery leads to changes in the continuity of body tissues. To maintain homeostasis, the body is a mechanism for immediate recovery of the tissue injury experience. In the recovery process is a chemical reaction occurs in the body so that the pain felt by the patient ( Fields, in Ani, 2010). In the operation process used anesthesia so that the patient does not feel pain during surgery. But after the operation is completed and the patient regained consciousness, he will feel the pain in the body that had surgery ( Wall & Jones, in Ani, 2010).

To prevent postoperative appendectomy complications in patients appendix, the patient must be done in accordance with the stages of early mobilization. Therefore, after having an appendectomy, patients are advised not to lazy to move after surgery, the patient should fast mobilization. The faster it moves, the better, but the mobilization must be performed carefully.

Early mobilization for Postoperative Appendectomy is an important aspect of the physiological function because it is essential to maintain independence (Carpenito, in Fitriyahsari, 2009). Patients feel healthier and stronger with early ambulation. With the move, the muscles of the abdomen and pelvis will be back to normal so that the stomach muscles become strong again and can relieve pain so the patient feel healthier and help gain strength and speed healing (Mochtar, in Fitriyahsari, 2009).

Pain by The International Association for the Study of Pain is a sensory and emotional experience that is not enjoyable, accompanied by tissue damage potential and actual. Pain is a condition that is more than just a single sensation caused by a particular stimulus (Potter & Perry, 2006). Pain is felt in the appendix postoperative patients can worsen the patient's condition and even cause many complications in the appendix.

The main complication of appendicitis is perforation of the appendix, which can develop into peritonitis or abscess. The incidence of perforation was 10 % to 32 %. Incidence is higher in young children and the elderly. Perforation generally occurs 24 hours after the onset of pain. Symptoms include a fever with a temperature of 37.7 ° C or higher, toxic appearance, and abdominal pain or tenderness of the continuous (Smeltzer and Bare, 2002).

Nursing Assessment - Physical Examination for Appendicitis

Risk for Deficient Fluid Volume - Nursing Interventions for Appendicitis

Appendicitis Pre- and Post-Operative Care Plan

Appendicitis Pre- and Post-Operative Care Plan

Surgical Nursing   October 27, 2013

Appendicitis Pre Operative Care:

• Sonde installation to decompress the stomach.
• Catheters to control urine production.
• Rehydration.
• Antibiotic with broad spectrum and is given intravenously.
• Fever-reducing medicines.
• If fever, should be reduced before anesthesia.

Appendicitis Operative Care :

• Appendectomy
• Appendix removed, if the appendix is perforated freely, then the abdomen was washed with physiological saline and antibiotics.
• Appendix abscess treated with IV antibiotics, its mass may shrink, or abscess may require drainage within a few days.
• Appendectomy done if the abscess performed elective surgery after 6 weeks to 3 months.

Appendicitis Post Operative Care:

• Observation of vital signs.
• Lift the stomach sonde when patients have realized that aspiration of gastric fluid can be prevented.
• Put the patient in a semi-Fowler position.
• Patients are said to be good when it is in 12 hours without any disturbance, during fasting.
• When the action is bigger operation, for example the perforation, fasting continued until bowel function returned to normal.
• Give drink from 15 ml / hour, for 4-5 hours, then raised it to 30 ml / hour. The next day give food strain, and the next day be given soft foods.
• One day after surgery the patient is advised to sit upright in bed for 2 × 30 min.
• On the second day the patient can stand and sit outside the room.
• Day 7 stitches can be removed and the patient allowed to go home.

In the appendix to the state of the masses who are still active inflammatory process that is characterized by:

• General state of the client it still looks sick, the body temperature is still high.
• Local examination of the right lower quadrant of the abdomen are still clear signs of peritonitis.
• Laboratory there are leukocytosis and the counts are shifting to the left.

Surgery should be performed as soon as the client is prepared, because it feared would happen appendix abscess and generalized peritonitis. Preparation and surgery should be done as well as possible given the complications of wound infection is higher than surgery in simple appendicitis without perforation.

On the state of the appendix mass with inflammatory process has subsided characterized by:

• General condition has improved with no visible pain, body temperature is not high anymore.
• Local inspection abdomen there are no signs of peritonitis and only clear and palpable mass with mild tenderness.
• Laboratory leukocyte count and differential count normal.

Actions taken should be conservative with antibiotics and bed rest. Surgery if the bleeding was more difficult and more, especially when mass appendix has formed more than a week since the attacks of abdominal pain. Surgery is carried out immediately if the treatment occurs abscess with or without generalized peritonitis.

Impaired Skin Integrity related to Cellulitis Care Plan

Impaired Skin Integrity related to Cellulitis Care Plan

Nursing Care Plan   October 27, 2013

Cellulitis is a skin infection that is caused by bacteria. The bacteria called Staphylococcus aureus and Group A Streptococcus are usually responsible for this kind of infection. Streptococci and Staphylococci can enter the skin to cause cellulitis infection through scrapes, cuts, wounds, blisters, insect bites and ulcers and find their way into the dermal and subcutaneous layers of the skin. Different cellulitis infections are facial cellulitis, breast cellulitis, orbital (eye) cellulitis, periorbital (eyelid) cellulitis, hand or arm cellulitis, perianal cellulitis and lower leg or foot cellulitis.

The main symptoms are skin redness or inflammation that spreads in size as the infection spreads , tight, glossy, stretched occurrence of the skin , tenderness of the area , skin injury or rash, sudden onset ,warmth over the redskin,fever .there are some other signs of infection includes chills, shaking, fatigue, warm skin, sweating, muscle aches, myalgias. Some of the additional symptoms that may be related with this disease are nausea, vomiting and hair loss at the site of infection.


Nursing Diagnosis and Interventions for Cellulitis

Impaired Skin Integrity related to changes in turgor

Goal: Demonstrate tissue regeneration.

Outcomes:

• Lesions began to recover and the free area of the infection,
• Clean skin,
• Dry and surrounding area free from edema,
• Normal temperature.

Nursing Intervention:

1. Assess the damage, size, color depth of the liquid.
R /: proper assessment of the wound and the healing process will assist in determining further action.

2. Maintain bed rest with an increase in limb and mobilization.
R /: Circulation that can smoothly accelerate the wound healing process.

3. Maintain aseptic technique.
R /: to accelerate the wound healing process.

4. Use the compress and bandage.
R /: Compress and dressing could reduce contamination from outside.

5. Monitor the temperature of the report, report your doctor if there is improvement.
R /: Early indications for infectious complications.